PCA - Marriott Hotel Site Development at Hall of Fame Phase I Proj No 116-021 - Majority Builders

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AFFIDAVIT AND WAIVER OF LIEN State of Indiana, County of St. Joseph SS: Rick.,Slagle being duly sworn that he/she is the President (Name of Officer) (Title) of Majority Builders, Inc. having contracted with City of South Bend Public Works (Subcontractor/Supplier) (Contractor) to furnish certain materials and/or labor asfollows: #116-021 Marriott Hotel Site Development Hall of Fame (Description) for a project known as #116-021 Marriott Hotel Site Development at Hall of Fame (Name of Project) located at St. Joseph Street South Bend, IN and owned by City of South Bend (Owner) and does hereby further state on the behalf of the aforementioned subcontractor/supplier: (PARTIAL WAIVER) that there is due from the Contractor the sum of Dollars ($ ) ❑ receipt of which is hereby acknowledged; or ❑ the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which is given solely with respect to said amount, and which waiver shall be effective only upon receipt of payment thereof by the undersigned; (FINAL WAIVER) that the final balance due from the contractor is the sum of fifty six thousand, eight hundred eighty ... 42/00 ($56,880.42) ❑ receipt of which is hereby acknowledged; or the payment of which has been promised as the sole consideration for this Affidavit and Final Waiver of Lien which shall become effective only upon receipt of such payment. THEREFORE, the undersigned waives and releases unto the Owner of said premises, any and all liens or claims whatsoever on the above -described property and improvements thereon an account of labor or material or both, furnished b the undersigned thereto, subject to limitations or conditions expressed herein, if any; and further certified that no other party has any claim or right to a lien on account of any work performed or material furnished to the undersigned for said project, and within the scope of this Affidavit and Waiver of Lien. > Majority Builders, Inc. By (Firm) (Authorized R esentative) STATE OF INDIANA ) ) SS: ST. JOSEPH COUNTY ) Before me, the undersigned, a Notary Public, in and for said County and State, personally appeared Rick Slagle and acknowledged the execution of the foregoing Affidavit and Waiver of Lien. IN WITNESS WHEREOF, I have hereunto subscribed my name and affixed my official seal on the 1st day of February $4IICX 2017• My Commission Expires: Residing in Elkhart 11/8/24 Notary Public Signature County, Indiana Shane Blotkamp Notary Public Name